Financial Questionnaire
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Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Please Select
Male
Female
Other
Date of Birth
-
Month
-
Day
Year
Date
Desired Retirement Age
Spouse's Name
First Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Spouse's Desired Retirement Age
Number of Children
Ages of Children
Current State of Residence
Current Concerns
Please check which toipc
Controlling Spending
Creating Your Own Family Bank
Eliminating Debt
Wills/Trust/Estate Planning
Reducing Taxes
Asset Protection
Planning for (grand)child(ren) education/future
Maximizing Savings
Future Expenditures
Back
Next
Real Estate
Personal Residence Information
Mortgage Payment(Principal & Interest)
Interest Rate(%)
Remaining Mortgage Balance
Extra Mortgage Pmt Amount
Mortgage Type
Fixed
ARM
Conventional
Jumbo
Other
Additional Real Estate Properties
Rows
Mortgage Balance
Mortgage Type
Mortgage Pmt(P&I only)
Mortgage Pmt(Taxes&Int)
Interest Rate(%)
Years Remaining(years)
1
Fixed Term (30yr, 15yr, etc)
Adjustable Rate Mortgage(ARM)
Interest Only
Other
2
Fixed Term (30yr, 15yr, etc)
Adjustable Rate Mortgage(ARM)
Interest Only
Other
3
Fixed Term (30yr, 15yr, etc)
Adjustable Rate Mortgage(ARM)
Interest Only
Other
4
Fixed Term (30yr, 15yr, etc)
Adjustable Rate Mortgage(ARM)
Interest Only
Other
5
Fixed Term (30yr, 15yr, etc)
Adjustable Rate Mortgage(ARM)
Interest Only
Other
Debt
Pleae list any debts other than mortgage
Rows
Type of Debt
Name
Amount Owed
interest Rate(%)
Minimun Payment($)
Actual Payment($)
1
Credit Card
Personal Loan
Auto Loan
Student Loan
2
Credit Card
Personal Loan
Auto Loan
Student Loan
3
Credit Card
Personal Loan
Auto Loan
Student Loan
4
Credit Card
Personal Loan
Auto Loan
Student Loan
5
Credit Card
Personal Loan
Auto Loan
Student Loan
6
Credit Card
Personal Loan
Auto Loan
Student Loan
7
Credit Card
Personal Loan
Auto Loan
Student Loan
8
Credit Card
Personal Loan
Auto Loan
Student Loan
9
Credit Card
Personal Loan
Auto Loan
Student Loan
Insurance
Tobacco Use(includes chewing tobacco, snuff, e-cig, vaping, hookah)
Yes
No
Please list all insurance information below
Rows
Insurance Type
Monthly Premium
Cash Value($)
Death Benefit($)
1
Whole Life
Term
Universal Life
Indexed Universal Life
Other
2
Whole Life
Term
Universal Life
Indexed Universal Life
Other
3
Whole Life
Term
Universal Life
Indexed Universal Life
Other
4
Whole Life
Term
Universal Life
Indexed Universal Life
Other
5
Whole Life
Term
Universal Life
Indexed Universal Life
Other
6
Whole Life
Term
Universal Life
Indexed Universal Life
Other
7
Whole Life
Term
Universal Life
Indexed Universal Life
Other
Insurance(Spouse)
Tobacco Use(includes chewing tobacco, snuff, e-cig, vaping, hookah)
Yes
No
Please list all insurance information below
Rows
Insurance Type
Monthly Premium
Cash Value($)
Death Benefit($)
1
Whole Life
Term
Universal Life
Indexed Universal Life
Other
2
Whole Life
Term
Universal Life
Indexed Universal Life
Other
3
Whole Life
Term
Universal Life
Indexed Universal Life
Other
4
Whole Life
Term
Universal Life
Indexed Universal Life
Other
5
Whole Life
Term
Universal Life
Indexed Universal Life
Other
6
Whole Life
Term
Universal Life
Indexed Universal Life
Other
7
Whole Life
Term
Universal Life
Indexed Universal Life
Other
Income & Expenses
Monthly Income
Rows
You
Salary/Wages
Social Security($)
Pension($)
Investment income($)
Rental income($)
Other income(child supp, disability, etc)
TOTAL MONTHLY INCOME
Monthly Expenses
Rows
You
Rent
Homeowner/Rental insurance
HOA/Condo fee
Electricity
Gas
Water
Cable/Wi-Fi
Cell Phone
Car insurance
Streaming subscriptions(Netflix, Hulu, etc)
Other monthly subscriptions(AAA, AARP, etc)
Membership(clubs,unions,associations)dues
Tuition/education-related expenses
Child support
Alimony/palimony
Court-ordered judgment/settlement
Tax-related repayment plans
Other
TOTAL MONTHLY EXPENSES
Discretionary Income
Monthly Income(spouse)
Rows
You
Salary/Wages
Social Security($)
Pension($)
Investment income($)
Rental income($)
Other income(child supp, disability, etc)
TOTAL MONTHLY INCOME(spouse)
Monthly Expenses(spouse)
Rows
You
Rent
Homeowner/Rental insurance
HOA/Condo fee
Electricity
Gas
Water
Cable/Wi-Fi
Cell Phone
Car insurance
Streaming subscriptions(Netflix, Hulu, etc)
Other monthly subscriptions(AAA, AARP, etc)
Membership(clubs,unions,associations)dues
Tuition/education-related expenses
Child support
Alimony/palimony
Court-ordered judgment/settlement
Tax-related repayment plans
Other
TOTAL MONTHLY EXPENSES(spouse)
Discretionary Income(spouse)
Do you expect a significant change in cash flow in the near future?
Yes
No
If yes, please explain:
Savings, Investment & Retirement Accounts
List account type(IRA, 401K, TSP, deferred comp, etc). Check the box if the account value, contributions, or both are available
Type a question
Rows
Financial Institution
Account Type
Account Value
Funds Availability
Contribution Amount
Contribution Availability
1
2
3
4
5
6
7
8
Any Asset Not Listed
Submit
Should be Empty: